Connecticut Department of Social Services Implements New Medically Unlikely Edits Review Process

December 2017 ~

The Connecticut Department of Social Services (DSS) recently released a memo announcing implementation plans for its process for reviewing claims denied solely due to exceeding the National Correct Coding Initiative (NCCI) Medically Unlikely Edit (MUE) limit for dates of service July 1st, 2016 and forward.

As stated in the memo:

Providers can request DSS review of claims with denied details due to exceeding an MUE with Explanation of Benefits (EOB) Code 770 “MUE Units Exceeded”. Claim details over the assigned MUE limit will be denied even if there is an approved prior authorization (PA) that would otherwise allow coverage of the service. If a claim denies solely due to exceeding the NCCI MUE limit, providers may submit a request to have the claim reviewed.

An electronic claim must be submitted following the guidelines set forth in Provider Bulletin 2017-49, “Electronic Claim Submission with Paper Attachment Process” for an MUE review. It must list all the services rendered on the denied claim. The detail that exceeded the allowed MUE must be broken out into two separate details. The first detail line should be submitted with the allowed MUE units and the remaining units must be submitted on a separate detail with the GD modifier. The electronic claim will be suspended for review.

In order for a claim to be reviewed, the following information must be submitted as a paper attachment:

  • a cover letter containing the original Internal Control Number (ICN) and written correspondence explaining the reason for the appeal; and
  • any other information that will support a determination by the Connecticut Medical Assistance Program (CMAP) that the service for which payment denied is medically necessary.

The information must be faxed or mailed to DXC Technology following the instructions for submitting paper attachments in Provider Bulletin 2017-49.

Overriding the MUE limit does not guarantee payment. The provider must also demonstrate that the claim was properly completed and submitted in accordance with all CMAP requirements, and that all other prerequisites for payment have been met. Claims that have exceeded the timely filing limits may not be submitted for review. Procedure codes assigned an Ambulatory Payment Classification (APC) status indicator that is considered packaged or non-payable should not be submitted for review.



Source(s): Connecticut Department of Social Services;